One of the most contentious and difficult aspects of trying to improve medical care in this country is enforcing a minimal “standard of care.” Optimally, this standard of care should be based on science- and evidence-based medicine and act swiftly when a practitioner practices medicine that doesn’t meet even a minimal requirement for scientific studies and clinical trials to support it. At the same time, going too far in the other direction risks stifling innovation and the ability to individualize treatments to a patient’s unique situation–or even to use treatments that have only scientific plausibility going for them as a last-ditch effort to help a patient. Also, areas of medicine that are still unsettled and controversial could be especially difficult to adjudicate. Unfortunately, with medicine being regulated at the state level, there are 50 state medical boards, each with different laws governing licensure requirements and standards for disciplining wayward physicians, our current system doesn’t even do a very good job of protecting the public from physicians who practice obvious quackery. The reasons are myriad. Most medical boards are overburdened and underfunded. Consequently, until complaints are made and there is actual evidence of patient harm, they are often slow to act. Also, in my experience, they tend to prefer to go after physicians who misbehave in particularly egregious ways: alcoholic physicians or physicians suffering from other forms of substance abuse; physicians who sexually abuse patients; or physicians who are “prescription mills” for narcotics. These sorts of cases are often much more clear-cut, but most importantly they don’t force boards to make value judgments on the competence and practice of physicians to nearly the extent that prosecuting purveyors of unscientific medicine does.

Dr. Rashid Buttar: Autism and cancer

The reason I’ve been thinking about this issue again is because last Friday it was announced that one of the most dubious of dubious physicians of which I have ever become aware, Dr. Rashid Buttar of North Carolina, was, after many years of practice, finally disciplined by the North Carolina Board of Medical Examiners. Basically, the Board restricted his practice so that he could no longer treat children or cancer patients (more on why those two particular restrictions were imposed below). Once hailed as a hero by antivaccinationists and even once having testified to the Subcommittee on Wellness & Human Rights on autism issues, he is now disgraced.

“All truth passes through 3 phases: First, it is ridiculed. Second, it is violently opposed, and Third, it is accepted as self-evident.”- Arthur Schopenhauer, 1788-1860.

I can’t resist mentioning that any time I see this particular quote, I know that I’m almost certainly dealing with someone who is far on the fringe, because what one first has to realize about the quote is that non-“truth” never makes it past phase one or two–and rightly so. Right off the bat, we can see that Dr. Buttar has a greatly inflated view of his own importance.
I first became aware of Dr. Buttar around three years ago in the context of his “transdermal” chelation therapy for autism. Regular readers may be aware that the whole concept of “chelation” therapy for autism is based on the scientifically discredited notion that mercury in the thimerosal preservative that used to be used in childhood vaccines until the end of 2001 is a major cause of autism. Based on this highly dubious concept, all manner of methods to “detoxify” these children of the mercury (and other heavy metals) that, according to antivaccinationists, are the cause of autism, have been used on autistic children. Chelation therapy involves using chemicals that can bind to the metal ions and allow them to be excreted by the kidneys, and indeed this is standard therapy for certain types of acute heavy metal poisoning. However, when it is used for coronary artery disease or autism, on a strictly stoichiometric and pharmacological basis, it is extremely implausible. Moreover, it is not without potential complications, including renal damage and cardiac arrhythmias due to sudden drops in calcium levels. Such arrhythmias can and have led to deaths (more later). Despite this extreme implausibility, randomized controlled studies showing that chelation is no better than placebo for cardiovascular disease, and no evidence at all that it does anything at all for symptoms of autism, a veritable cottage industry of chelation therapy for cardiovascular disease and autism has sprung up. With most regimens costing $100 to $150 a treatment and “requiring” 30 to 40 doses, it’s a tidy little profit center for “alternative” physicians.

Dr. Buttar made his name in the autism community by coming up with a form of chelation therapy that did not involve intravenous medication, which led him to be lionized by boosters of the “mercury causes autism” such as Generation Rescue. He took an accepted chelator used for acute heavy metal poisoinging, including mercury, called DMPS, formulated it as a paste or cream, and dubbed it “transdermal” DMPS or TD-DMPS, or, as some wags have dubbed it, “Buttar’s butter.” His main claim is that it’s safer. Of that there is little doubt, but that’s because Dr. Buttar has either utterly refused or been unable to provide even the barest modicum of evidence to suggest that the DMPS is absorbed through the skin and into the bloodstream. That is the most basic question that any science-based physician would ask about any transdermal medicine, and Dr. Buttar’s reactions to such questions is very telling. For instance, Prometheus quotes him:

In answer to questions of whether he has tested to see if his transdermal DMPS (TD-DMPS) drops are, in fact, absorbed through the skin –

No, we haven’t done that. Why would I waste my time proving something that I already know is working innately?

And, in response to being challenged on this point, Dr. Buttar wrote in an e-mail exchange with a supporter of his named Pat Sullivan:

My purpose is not to prove that TD-DMPS is getting through the skin Patrick. I don’t care if it is a placebo, which obviously it isn’t….and our lancet paper

It is a “SAFETY” issue I’m talking about….I don’t care to prove a damn thing to those people that you have been dueling it out with.

In a later e-mail, Dr. Buttar wrote:

You see, first, you would have to actually have to have some type of test developed to actually detect the DMPS in it’s altered form as it is absorbed. That takes money, effort and time. As my friend says, why do it? Let someone who wants to establish biokenetics and half life do that. It is not necessary to do this from a clinical efficacy standpoint. It would be nice to know how it works, but it is irrelevant. It works based on empirical evidence.

So it’s absorption is not an issue for me or for anyone who is a true scientist because the empirical evidence is abundant. Only a pseduo scientist is going to get caught up with levels in serum, which it may not even show, since DMPS is highly neurophillic and may be possibly taken up by the nerves or distributed through the lymphatics…I don’t know and I frankly don’t care since it has no relevance to the clinical side of the house. But you see how absurd it is to simply assume it has to get into the serum? It most likely does, but it may not. The point is, it gets in and it works….and it works better than anything else out there.

Yes, Dr. Buttar “knows” his treatment works, based on his “clinical experience.” He don’t need no steekin’ science, like bothering to show that his drug actually gets absorbed through the skin into the bloodstream. (Never mind that Dr. Buttar has been promising a study since 2004.) This seems quite odd, given that it would in fact be pretty straightforward to document whether the DMPS is getting into the bloodstream and if it is actually chelating heavy metals. Why on earth would he not want to do it? Of course, as we know, the plural of “anecdotes” is not “data,” as Steve Novella has pointed out, and, as Prometheus has pointed out, autism is a syndrome of developmental delay, not developmental stasis, which is why randomized studies with a placebo-control group are so critical. Particularly telling is Dr. Buttar’s statement that he “doesn’t care if it’s a placebo.” Little more needs to be said about his attitude about science, but that hasn’t stopped him from promoting this unproven and dubious therapy for autism for several years now.

More recently, Dr. Buttar developed a new “protocol” for treating autism that involved more than just chelation therapy. It is described here by a parent who saw him for a consultation a couple of years ago:

Every 2 weeks our son will get IV EDTA and ozone (which will be infused in his blood and given via IV) and on the second day he will get minerals. The reason given for ozone is to reduce persistent organics in his system. There is no test being recommended to determine if the child will be a good candidate for ozone. Apparently, some children are seeing good results and Dr Buttar is trying this treatment on older children (greater than 7). Dr Buttar’s office has provided some research on ozone done by a MD researcher in NY whom we spoke with. The immediate reaction of this researcher was that there has not been any study with children while ozone therapy is safe and has been used on millions of people in Europe. The researcher was not aware of Dr Buttar or his protocol on children and said that one needs to establish first if ozone therapy is needed.

There is no biologic plausibility or evidence to support the use of such a regimen. But Dr. Buttar has reportedly gone even beyond this level of dubiousness. As reported by Kevin Leitch, parents on a Yahoo! discussion group about chelation therapy for autism were reporting in 2006 that Dr. Buttar was recommending, well, let Kevin describe it. First, a parent asks:

Have any of your tried, or even heard anything about, doing urine shots to help the immune system? I don’t know much about it yet, but I know you use your child’s own urine, and filter it with special filters, before injecting it into their hip. I’ve heard really good things about it from a friend who tried it.

Here are some answers:

“This was recommended by Dr. Buttar’s office for my NT son who has tons of allergies. I believe Dr. Imam in NY does it. It sounded too “out there” for us so we are currently sticking with justchelation for him.”

“My grandson went through this beginning in October. It was a once a week treatment for 10 weeks. Before he began, he had lots of allergy problems that would often advance into sinus infection and ear infections. It’s almost April and he has not had one problem since. The only thing that I see is an occasional stuffy nose that lasts only a very short time.”

“I only know this was described to me to be a procedure used by Dr. Buttar about a year ago when my son was his patient, but the nurse said it would require an extended stay near the clinic and we live in Texas. We never tried it and moved on to another doctor.”

Just in case you think you read it wrong, you didn’t. Rashid Buttar and others recommend taking some of the childs urine, filtering it and then injecting it back into them. This is apparently good for the immune system. Yummy.

Yummy, indeed.

Arguably even more egregious is Dr. Buttar’s treatments for cancer patients. Let’s see what Dr. Buttar says on his own website about how he treats cancer:

The standard method of treating cancer is comprised of a combination of chemotherapy, radiation and surgery. However, according to the conventional, traditional medical literature, 75 to 95 percent of all cancers are related to some type of toxicity which results in damage to the immune system. Also, 42 percent of all cancer patients die of malnutrition. Yet, how many doctors treating cancer address nutrition or help repair the immune system? Learn the 5 step treatment approach Dr. Buttar uses in repairing the immune system in conditions such as cancer and AIDS. Then reach your own conclusion.

Medical board documents don’t name the four patients whose cases are cited. But Stephanie Kenny, a Charlotte mother of three, told The Charlotte Observer she is one of those who complained, on behalf of her husband, Jeffrey Kenny.

After learning that his adrenal cell cancer had returned following surgery, Jeffrey Kenny sought help from Buttar in early 2004. “He said it didn’t matter what kind of cancer anybody had, he could cure it,” Stephanie Kenny said. “He kept reiterating he had a 100 percent success rate.”

And:

Jerry Messina, of Los Angeles, told The Charlotte Observer he also complained to the medical board on behalf of his aunt, Lori Kostin. He said she went to Buttar after three rounds of chemotherapy failed to cure ovarian cancer. The medical board said Kostin paid $10,000 of a $30,000 bill for two months of treatment with IV infusions.

Messina, who did not meet Buttar, said his aunt told him the doctor “treated every type of cancer the same” and bragged about his 100 percent success rate. Two weeks before she died, in November 2004 at age 52, “she just flat out told me `I wish I’d never gone to this Dr. Buttar,'” Messina said. “She felt that her cancer got a lot worse.”

It should be noted that Dr. Buttar claims that he has patients sign a form that “no claim to cure cancer with these therapies has been made.” Be that as it may, anyone, doctor or not, who claims that he or she has a 100% success rate in curing cancers like the ones described above is either deluded or a liar. Period. Not even cancers for which there is a good prognosis and for which we have very effective treatments are cured 100% of the time. Moreover, it is incredibly unethical to make such a claim and then accept tens of thousands of dollars for these treatments. Even worse, like the Gonzalez regimen, Dr. Buttar’s cancer regimen is very onerous for cancer patients to follow. Indeed, one of Dr. Buttar’s patients, a man with prostate cancer who has posted under the pseudonym Cajun Cowboy, summarized his regimen, and it’s incredible. It turns out that Cajun Cowboy was at first a big fan and happy patient of Dr. Buttar, but now he says:

All the information about Dr. Buttar is still on this site but I no longer am one of his patients and I do not recommend him to any one for any reason. If you go to him for treatment BEWARE, BEWARE and read Roger Mason’s books first and go to QuackWatch.org first!

His description of Dr. Buttar’s billing practices is heartbreaking, and Dr. Buttar has been known to go after patients’ estates for uncollected bills. Meanwhile, one of the Board recognized a cardinal sign of questionable medicine:

“Doesn’t it strike you as a little strange that every patient that comes through your door has heavy metal toxicity?” Dr. Art McCulloch, a Charlotte anesthesiologist, asked Buttar’s nurse practitioner, Jane Garcia.

I assume the question was rhetorical, as anyone who has taken the time to study such practitioners knows that giving the same diagnosis and treatment to every patient is practically pathognomonic of quackery.

The reason I’ve gone on so long about Dr. Buttar is first simply to show just how outside of the standard of care Dr. Buttar’s practice of medicine has been. Kathleen Seidel has documented all of the complaints leveled by the NC Board against him, and I encourage everyone to read it. My second purpose is to point out just how powerless the North Carolina Board of Medical Examiners seems to have been for so long. Yes, it is taking action now and has specifically restricted Dr. Buttar’s practice to exclude cancer patients and children (the latter of which should stop his treating autistic children), but Dr. Buttar practiced this way for several years and continued to do so in the many months during which the Board’s proceedings against him ground along. Moreover, it’s by no means clear that the Board’s recommendation against him will stand. Dr. Buttar has deep pockets and can indeed afford to fight this action all the way to the North Carolina Supreme Court. I have no doubt that he will try to do just that. Even worse, even if he loses, his license is not being taken away. He will still be able to practice, just not on cancer patients or children. There’s nothing in the Board’s recommendation that would prevent him from treating patients with cardiovascular disease with his TD-DMPS.

Other practitioners of dubious therapies

If Dr. Buttar were just one example of an “alternative” practitioner who manages to get away with practicing non-science-based medicine that does not help patients and arguably harms them, one might dismiss him as nothing more than an anomaly. However, just in the realm of autism alone, he is not alone. Dr. Roy Kerry, for instance, is an otolaryngologist near Pittsburgh who apparently has given up head and neck surgery and devoted himself to dubious allergy treatments and various “alternative” medical modalities, who killed an autistic child in 2005 with chelation therapy. Yet, despite this, the CDC got it wrong about why this happened, and it took nearly two and a half years before any substantive action was taken. I will give proper credit to the State of Pennsylvania, though, that Dr. Kerry will soon stand trial for negligent homicide, although I can’t resist pointing out that Dr. Kerry still has a license to practice medicine and has continued to see patients since 2005. I have no doubt that if the autistic boy Abubakar Tariq Nadama had not died, Dr. Kerry would still be happily chelating autistic children with no inteference from the government.

If Dr. Buttar and Dr. Kerry are two who actually are being brought to justice for their offenses against medicine, however, more are like the case of Dr. Mark Geier, who has served as an expert witness in numerous lawsuits against vaccine manufacturers. He has had, as far as I know, no actions taken against him by the Maryland Board of Physicians. Describing in detail the number of questionable and unscientific practices that Dr. Geier inflicts on autistic children would be the topic for another blog post entirely, but I can summarize them with a short list of links:

Advocates for science-based medicine cannot help but be appalled at how easily physicians practicing modalities that are clearly far outside the standard of care can continue to do so with little or no interference by state medical boards. In essence, it takes particularly egregious offenses to motivate a board to act, be it substance abuse, non-science-based treatments resulting in the death or severe injury of a patient, or blatantly illegal behavior. Part of the problem is that the attitude among doctors seems to be that a medical license is a right, not an incredible privilege bestowed upon us by society that takes an equally incredible commitment and skill to be allowed to keep. Physicians who are on these boards are also often unpaid and reluctant (as they see it) to strip a fellow doctor of the means of his or her livelihood. There’s also a cultural tendency among physicians to stick together. We understand the difficulty of making decisions that can have profound consequences in our patients’ lives, and we tend to want to bend over backwards to give fellow doctors the benefit of the doubt. Our patients deserve better. The vast majority of physicians are competent and try their best to deliver the best evidence-based care they can to their patients. However, doctors who consistently do not practice according to the standard of care, be it because they are incompetent, dishonest, impaired by substance abuse, or because they have come to believe in blatantly unscientific treatments that do not help and not infrequently harm patients, do not deserve to be physicians. Examples such as Drs. Buttar, Kerry, and Geier show that our system is broken. If we as a profession do not find a way to do better, I fear that legislators will do it for us.